DOI: 10.1097/JPN.0b013e31823f0284
C 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
J Perinat Neonat Nurs r Volume 26 Number 1, 27–36 r Copyright Relationship-Based Nursing Practice
Transitioning to a New Care Delivery Model in Maternity Units
Cathleen C. Hedges, MSN, RN, B-C; Amy Nichols, EdD, CNS, RN; Lourdes Filoteo, BSN, RN
ABSTRACT
In a fast-paced, high-volume maternity unit, the goal for
nursing care delivery is to provide care that is perceived
by patients as personal and caring, is rewarding to nurses,
and is in an environment of maximum patient safety. A
care delivery model is the organizing structure that can facilitate this goal. Relationship-Based Nursing Practice is
a care delivery model designed to transition nursing care
from task-focused to relationship-based. A shared vision
of the registered nurse as a professional member of the
healthcare team, working in an optimally safe and familycentered care environment, inspired the model design.
Three relationships—the nurse with the patient, the nurse
with colleagues, and the nurse with self—provided the
foundation for the creation of guiding principles. Guiding
principles were operationalized to support 1 or more of
the 3 relationships, contribute to improved patient safety,
and actualize the role of the professional registered nurse,
in daily patient care. Outcomes include improvement in
patient safety, increased patient satisfaction, and perception of improved teamwork among nurses. The process
for sustainability and ongoing evaluation of the model is
discussed.
Key Words: briefing-debriefing, care delivery model,
handoff communication, nurse handoff, nurse-patient
relations, relationship-based, team attitude
Author Affiliations: Center for Nursing Excellence, Lucile Packard
Children’s Hospital, Menlo Park, California (Ms Hedges); and SFSU
School of Nursing, and Center for Nursing Excellence, Lucile Packard
Children’s Hospital (Dr Nichols), and Johnson Center for Pregnancy and
Newborn Services, Lucile Packard Children’s Hospital (Ms Filoteo), Palo
Alto, California.
Disclosure: The authors have disclosed that they have no significant
relationships with, or financial interest in, any commercial companies
pertaining to this article.
Corresponding Author: Cathleen C. Hedges, MSN, RN, B-C, Center
for Nursing Excellence, Lucile Packard Children’s Hospital, 4700
Bohannon Dr, No. 150, Menlo Park, CA 94025 ([email protected]).
Submitted for publication: July 15, 2011; accepted for publication:
October 26, 2011.
The Journal of Perinatal & Neonatal Nursing
ince the release of the Institute of Medicine’s
(IOM’s) report, To Err Is Human,1 agencies and
organizations such as the Agency for Healthcare
Research and Quality, the IOM, the National Quality
Forum, and The Joint Commission have made recommendations and put requirements in place to address
patient safety. In addition, the Lucian Leape Institute,
established by the National Patient Safety Foundation,
states that patient safety depends on a significant transformation to achieve a culture of trust, reporting, transparency, and discipline.2 This vision for healthcare
includes doctors, nurses, and all healthcare workers
who treat each other with respect, patients’ interests are
foremost, and patients and families are fully involved in
their care. One key attribute of such a culture is transparency, so that everyone is encouraged and given the
opportunity to talk openly about errors and mistakes.
A second attribute is joy and meaning in work; to meet
the challenge of making healthcare safe and caregivers
feel valued.2 At the core of such a cultural transition
for nurses are 3 types of relationships. These relationships comprise nurse and patients; nurse and coworkers, management, and other members of the healthcare
team; and nurse and self, in self-advocacy, autonomy,
and responsibility for the safe and effective care of patients and families. The purpose of this article is to
describe the design, the implementation process, and
preliminary outcomes of a relationship-based nursing
care delivery model with specific examples in maternity units.
S
CURRENT STATE OF NURSING
CARE DELIVERY
In a tertiary care, university-affiliated children’s hospital
with full obstetric services and approximately 5000 deliveries annually, a significant transition in nursing care
delivery was undertaken to realign priorities of care
with the vision and goals of the organization. Before
implementation, patient care was largely task driven
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27
with an emphasis on moving patients through their
hospital stay as quickly as possible. In this functional model, care was provided primarily by registered
nurses (RNs). However, the professional RN’s role was
poorly understood by nurses and other members of
the healthcare team alike. Because of 12-hour shifts,
rapid turnover of patients, and frequent adjustments
to staffing patterns, continuity of care was a daunting
challenge in the fast-paced, often-chaotic work environment. Critical thinking and clinical judgment were
difficult to incorporate into nursing assessments. Nurses
were hindered in their ability to develop therapeutic relationships with patients and families, to participate in
team rounds, and to proactively plan the patient’s care.
Handoffs were memory based and variable in quality
and did not enable safe transfer or continuity of information needed for coordination and care planning.
Teamwork was hit or miss. The patient experienced
fragmented care from shift to shift, which was often
perceived as impersonal and lacking coordination. The
hospital needed to transition nursing practice to a new,
transformative culture.
This transition began with a vision put forth by the
chief nursing officer. The 3 goals for achieving the cultural change were to focus nursing practice on caring
where the top priority is building and maintaining a
therapeutic relationship with the patient and family; establish a clear, tangible RN presence within the healthcare team; and clearly define and operationalize the
role of the RN as a coordinator of the patient’s plan of
care. A nursing care delivery model was needed to provide the infrastructure for cultural transformation. The
purpose of a care model is to organize the work that
nurses do. It provides common language, formal structure, and processes for delivering optimal patient care.
A care model defines the decision-making authority and
responsibilities of the nurse and others in the healthcare
environment, as well as work distribution, communication, and management.3 By focusing on a relationshipbased approach, the model would help transition patient care and the unit environment to a more optimal
patient experience. This model would need to include
core principles to guide nursing practice, roles and responsibilities of the RN and leadership, processes and
tools, and desired outcomes for success.
REVIEW OF THE LITERATURE
There are several reports in the literature of a relationship between better care environments and better patient outcomes.4−6 Care delivery models based
on caring theories and relationships have shown improvements in overall patient satisfaction,7 specifically
in concern for privacy, meeting emotional needs, at28
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tention to special/personal needs,8 and pain control.7,8
Caring-focused care delivery models have demonstrated a positive impact on nursing retention,7,9
nursing satisfaction,7 and specific improvements in
nurse-to-nurse relationships including mutual respect,
gossip avoidance, decreased complaining, and nurseto-nurse conflict resolution.10 Relationships between
patients and nurses, and nurses and coworkers, are
common threads found in caring-focused care delivery
models.
The philosophy and vision of nursing, and the organization’s mission and values, must be in alignment
with the tenets of the care delivery model and provide the basic foundation.11,12 Traditional care delivery models (total patient care, functional nursing, team
nursing, and primary nursing) have advantages and disadvantages and were developed to address past socioeconomic and cultural values in healthcare.13 These
models focused on delegation of duties and work allocation. Looking beyond division of workload and
considering the work environment, a caring-focused
care delivery model was needed to best achieve the
organization’s vision of family-centered, relationshipbased care that would optimize patient safety, cost, and
quality.
The organization wanted to improve the care environment, specifically teamwork and relationships
among nurses and other colleagues through the process of team briefing and debriefing. The aim of team
briefing and debriefing was to promote a sense of teamwork and professionalism, provide a consistent forum
to provide input about safety and operational issues,
and foster the relationship of the nurse with coworkers
and colleagues. The concepts of briefing and debriefing
have been in use among commercial and fighter pilots
and were formalized in Crew Resource Management
training by the National Aeronautics and Space Administration in 1979.14 Briefing and debriefing in the hospital setting have been studied primarily in the operating
room setting15−17 and have been shown to reinforce
professionalism and improve communication.17,18 Debriefing has allowed for the identification and analysis
of recurring problems through real-time reporting.17,19
Nurses, surgeons, and anesthesiologists report that patient safety in the operating room has improved with
briefings and debriefings.19 The Salas Theory of Teamwork supports fostering teamwork through team briefing, which provides the shared knowledge necessary
for a functioning team. The group is made aware of
itself as a team, communicates the possible need for
backup (helping each other) and adaptability (adjusting
to work environment changes), and establishes team
leadership. Mutual trust can be fostered through mutual understanding of the work to be performed.20
January/March 2012
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Communication across a shift or episode of care can
be fragmented with 12-hour shifts, part-time workers,
and variable lengths of stay. The organization aimed to
improve continuity of clinical and psychosocial information by addressing the change of shift RN handoff.
The IOM’s report, Crossing the Quality Chasm,21 urged
that healthcare organizations standardize the handoff
process, linking patient safety with ensuring that information is not lost or forgotten during transitions in care.
In 2005, The Joint Commission22 found that nearly 70%
of sentinel events in hospitals were caused by communication issues, and the majority of these occurred during handoffs, which led to the creation of a National Patient Safety Goal requiring standardized handoffs. The
World Health Organization23 and others24 urge the use
of common language and a standard communication
tool such as Situation, Background, Assessment, Recommendation (SBAR). Standardized handoff communication can decrease adverse events and increase patient
safety. It has been shown to improve compliance with
medication reconciliation upon admission, which can
reduce medication errors.25,26 In a pilot study, the use
of standardized nurse handoff communication using an
Electronic Medical Record (EMR)–supported SBAR tool
was related to a reduction in adverse nurse-sensitive
outcomes, which are monitored and reported to the
National Database for Nursing Quality Indicators. These
included a reduction in patient falls, use of restraints,
and catheter-associated urinary tract infections.27 The
literature was clear that a standardized RN handoff had
the potential to improve patient safety and continuity
of information by improving the transfer of information
between nurses at the change of shift.
The concept of focus time was identified to provide
structure to daily nurse-patient engagement. A cornerstone of building and maintaining therapeutic relationships between patients and nurses involves spending
dedicated time with patients to understand their needs
and concerns. Upon implementing Relationship-Based
Care (RBC), 1 hospital found that both verbal caring
behaviors (eg, discussing a topic of patient concern
other than current health needs) and nonverbal caring behaviors (eg, sitting at the bedside, sustaining eye
contact, and entering a patient’s room without having
been summoned) increased among nurses.9 One of the
key elements of the Caring Theory28 is that direct caregivers sit at the patient’s bedside for at least 5 minutes
each shift to review and discuss the plan of care and
desired outcomes. Within the Quality-Caring Model,7
purposeful interaction is described as a caring practice
in which the nurse sits down at the patient’s bedside,
looks at the patient, and initiates a conversation starting with something meaningful to that patient. These
behaviors have been related to improved patient satThe Journal of Perinatal & Neonatal Nursing
isfaction related to nurses anticipating needs, responding to requests,7,28 explaining procedures, and calming
fears.28
DESIGN PROCESS AND DESCRIPTION
Relationship-Based Care3 provided the inspiration for
the care delivery model. The fundamental construct of
RBC involves 3 relationships: the nurse and the patient, the nurse and colleagues, and the nurse and self.
When optimized, this model can result in safe, patientcentered, well-communicated, and well-coordinated
care. Clearly articulating the responsibilities, authority,
and accountability of the professional nurse optimizes
the role of the RN. Expectations of the role can be
communicated to providers for better collaboration and
coordination of care. These concepts resonated with
the goals of creating an environment in which care is
a priority and nurses are contributing members of the
healthcare team. The focus on relationships with patients and families paralleled the hospital’s core value
of family-centered care.29
A project plan was developed that included initial input from nurses.30 Successful implementation requires
customization of the model for integration into the existing organizational system and infrastructure. This process acknowledges the strengths and best practices in
patient care that currently exist and focuses on how
to reach excellence.31 The IOM’s report, The Future of
Nursing32 recommends that healthcare organizations involve nurses in developing and adopting new patientcentered care models. The input from frontline nurses
was essential in developing a model that would be realistic and achievable. The design team consisted of staff
nurse representatives from councils within the nursingshared governance structure, managers, and clinical
nurse specialists. In a preparatory workshop, the team
became grounded in the principles of RBC; the roles,
responsibilities, and scope of practice of the RN; and
the philosophy and vision for nursing at the organization. The 4 elements of a successful care delivery
model, which are the nurse-patient relationship and
decision making, work allocation and/or patient assignments, communication among members of the healthcare team, and the management and leadership of the
unit or care area, provide additional direction.33 The
team developed 5 guiding principles related to the concepts learned in the workshop and 7 practices that operationalized the principles (see Figure 1).
Because the care delivery model was specific to the
organization and its vision, it was named “RelationshipBased Nursing Practice” (RBNP). A shared governance
leadership council comprised of RN unit council coordinators and nursing management gave feedback and
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29
RelationshipBased Nursing
Practice
PRINCIPLE: Clinical
Decision Making:
Knowing the Patient
Maternity Units
Principles and
Practices
Date:
Supporting the
Relationships
Unit:
PRACTICE: Focus Time
PRINCIPLE: Work
Allocation and Patient
Assignments:
PRINCIPLE:
Coordination,
Communication, and
Collaboration
Nurse and
Patient
PRACTICES:
•! Standardized Handoffs
•! Patient Care Rounds (Phase 2)
•! Integrated Plan of Care (Phase 2)
PRACTICE: Continuity
of Care
Nurse and
Colleagues
PRINCIPLE:
Professionalism and SelfCare
PRINCIPLE:
Leadership and Team
approach
PRACTICE: (Phase 2)
PRACTICE: Team
Briefing and Debriefing
Figure 1. Relationship-based nursing practice: Principles
and practices supporting the relationships. Used with permission from Lucile Packard Children’s Hospital.
input to the creation of RBNP. The 7 practices that operationalize the guiding principles are described below.
Team briefing and debriefing
Principles taken from Crew Resource Management
briefing and debriefing and adapted for the care delivery model include punctuality, which sets a tone of
professionalism and respect, using a briefing checklist,
introducing members of the team, and identifying potential patient care issues.17 The team briefing begins
immediately at the start of each shift with the off-going
charge nurse briefing the oncoming unit staff about
what to expect for the coming shift. A briefing checklist is used, and in the maternity units, this checklist
includes such information as most critical or unstable
patients, for example, those on magnesium infusions or
on isolation, expected admissions and discharges, and
which nurse may have the heaviest assignment (see
Figure 2).
The charge nurse includes the shift staffing status,
and whether additional staff will be coming in to assist
with discharges or with patients in antepartum. When
the off-going charge nurse describes what to expect,
the oncoming nurses gain a shared mental model of
the shift ahead. The oncoming nurses become aware
of possible adjustments that may be needed, where
strengths and challenges may lie among the team and
patients, who may need help, and who is available to
help.
Debriefing occurs within the final 2 hours of each
shift. The aim is to give nurses the opportunity to be
heard and supported about operational and interpersonal issues, thus enhancing the nurse relationship with
30
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/ Stop Time:
NOTES
TOPIC
(Phase 2)
Nurse and
Self
Start Time:
AM
PM
Staffing (Unit appropriately
staffed? RNs, NAs, USAs?)
# of patients on the units?
F1/F2
# of expected discharges?
F1/F2
# of possible discharges?
F1/F2
Sickest patients on the unit?
(e.g., high acuity, MgSO4,
1:2 ratio, isolation)
Fetal Demise /Condition of
baby
Any procedures expected?
(e.g., CT, MRI, US, PICC,
Tubal,
Circ, L&D events)
Any patients with
confidentiality
status? (e.g., Visitor / phonecall
restrictions / social issues?
Which RN has heaviest load?
Stork Award recipient /
Orientees / New Grads /
Nursing
students working this shift?
New Protocols / Updates /
Policies (if applicable, refer
colleague to policy or e-mail)
Systems upgrade/downtime,
Meetings / Celebrations
Briefing given by:
Figure 2. Team briefing checklist. Used with permission
from F1/F2 units, Lucile Packard Children’s Hospital.
colleagues, as well as enabling near real-time reporting
of patient-safety issues. Either in a group or individually,
the charge nurse, assistant nurse manager, or manager
elicits input from each nurse. In maternity units, the
debriefing can include issues related to management
of critical incidences, such as postpartum hemorrhage,
difficulties with other departments, or other problems
within the unit. The issues are logged on a debriefing
checklist and addressed by the management team (see
Figure 3).
Management then communicates the issues, actions
taken, and follow-up status back to staff either in staff
meetings or by posting the issues and follow-up. Debriefing promotes a more transparent culture of error
reporting, as nurses are encouraged and supported to
share their experiences and to provide input during debriefing sessions on every shift.
Standardized RN handoff
There were several compelling reasons to include a
standardized RN handoff process in this care delivery
model implementation. Nurse-to-nurse, change-of-shift
reporting was based on a written report worksheet;
January/March 2012
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Maternity Units
Debriefing Checklist
(Occurs 16:30 and 04:30 daily)
Start Time:____________/ Stop Time:____________/Date:_____________
Lead By:
What worked well during the shift?
Who would you like to appreciate?
What needs changing for next time?
Patient Safety Concerns?
How did (pick one process from list) it go today?
Team briefing, Assignments, RN handoff, 5-min focus, Rounding, Team debriefing,
Figure 3. Maternity units debriefing checklist. Used with
permission from F1/F2 units, Lucile Packard Children’s
Hospital.
however, the EMR was the source of truth for realtime, accurate information and was not being reviewed.
With no visualization of patients at change of shift, there
were sometimes discrepancies between the information
given in reports and actual patient conditions. Critical
information was left to hand-written notes or memory.
The design team wanted the RN handoff to support
relationship-based nursing by enabling nurses to hand
off not only patient information but the relationship
as well. On the basis of the literature review, the new
standardized RN handoff process included SBAR format.
The team developed an electronic documentation form
designed to capture the details unique to each patient.
These details included an assessment summary statement; ongoing medical, psychosocial, and cultural concerns; recommendations such as patient/family preferences and interdisciplinary recommendations; priorities
for the next shift and day; and goals for discharge.
This information then flowed to a new RN handoff tab
in the EMR, customized for the unique clinical information needs of each unit or region. For example, in
the mother’s EMR, current weight, gravidity/parity, reason for cesarean delivery, resulted laboratory values,
attending physician and contact numbers, anticipated
The Journal of Perinatal & Neonatal Nursing
discharge date, and last charted values for fundal height,
fundal tone, position, lochia color and amount, and estimated blood loss were pulled from other documentation to the RN handoff tab. The infant’s RN handoff
tab included Apgar scores, current weight, birth weight,
lactation consult status, last stool and void, and last
feeding. A standardized process for reviewing the EMR
in SBAR format was designed to reduce memory-based
handoff communication. The situation and background
are reviewed from the patient summary tab, which includes presenting diagnosis, history of present illness,
significant hospital events, and physiologic data in summary format. Additional background and current situation information along with assessment and recommendations are discussed using the RN handoff tab. Review
of current orders, the medication administration tab,
and the care plan ensured that all current relevant information was reviewed and validated. The face-to-face
process provides the opportunity to ask and respond to
questions. The nurses completed a joint visualization at
the bedside, a timely assessment during shift change,34
which includes review of therapies, infusions, catheters,
tubes, drains, and any pertinent assessments, such as
wounds and other relevant physical characteristics of
the patient. To inform the patient and family of the
change of care provider, the off-going nurse introduces
the oncoming nurse,35 explains what will happen over
the subsequent few hours, and instructs to ask whether
the patient has any concerns.34 With couplet care, an
abbreviated handoff process and checklist are used for
handing off relevant information about the infant, for
example, pertinent laboratory test results and breastfeeding status. Both mother and infant are included in
the bedside joint visualization.
Focus time
Focus time is the intentional, uninterrupted communication intervention between the nurse and the patient
or family on each shift. The aim of focus time is to
assist the patient and nurse in establishing and maintaining a therapeutic relationship. It enables the nurse
to learn what the patient or family is most concerned
about and to identify support needs, which can facilitate patient participation in care planning. When nurses
are being educated about focus time, a common sentiment is that nurses already do this task, so there is
no need to relearn it. Although nurses do spend time
talking with patients and families, it is often done while
they are multitasking, with the nurse standing and looking down at the patient. The nurse is often interrupted
or may focus discussions on what is most important
for the nurse to accomplish. The practice of focus time
is intended to convey that nothing else matters at that
time but the patient.
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31
Continuity of care
Continuity of care can contribute to the enhancement
of clinical outcomes through a better understanding of
the clinical response over time and can lead to more
effective clinical decision making.36 In designing this
practice, the team emphasized the prioritization of assignment making in which continuity of assignments
was the first priority when acuity and skill levels were
not a consideration. In addition, the practice of continuity of care is translated into continuity of information, so
any nurse can become familiar with the patient’s clinical and psychosocial picture. From shift to shift, during
break coverage and rapid changes in assignments, continuity of information is maintained on the RN handoff tab in the EMR. Further work in phase II of the
project will address staffing and scheduling to promote
continuity.
Role of the RN in rounds
Nurses must overcome many systemwide barriers to
be able to consistently attend rounds. A multiplepatient assignment often means multiple sets of
rounds. In the university-affiliated medical center,
teaching rounds, subspecialty rounds, and interdisciplinary rounds, among others, each occurring at different times and/or overlapping, pose a major challenge to
the bedside nurse. The initial goal in this care delivery
model is for each nurse to attend rounds on a minimum of 1 patient of his or her assignment. The aim
is for physicians and nurses to experience better communication and coordination of care, thus supporting
the changes required to standardize rounds scheduling and roles. As a part of phase II of the project, the
medical center is collaborating with its physician teams
to schedule and structure rounds that will enable the
active participation of the bedside nurse in shared decision making about the plan of care for the patient.
Coordination of the plan of care
To operationalize a truly interdisciplinary patient plan
of care, where the goals for the patient from the medical
team, ancillary services, and nursing are in 1 location,
the team is redesigning the care planning functionality
of its EMR, as a part of phase II. In the meantime, the
care delivery model is the vehicle for defining the role
and responsibilities of the RN as the coordinator of care.
The nurse learns what is most important in the care of
the patient from focus time and communicates that in a
standardized handoff to other nurses. By participating
in rounds, the nurse takes information to and from the
healthcare team. Focus time, handoffs, and participating
in rounds provide the nurse with necessary tools and
information to manage the patient’s plan of care.
32
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Implementation
The care delivery model was implemented in 1 unit or
care area at a time in a wave approach.31 This method
allowed each care area to further customize the practices to apply to the patient care context, while meeting
the intent of the guiding principles. With each wave, the
project team and nursing leadership learned to develop
best practices that were shared with the next unit or
care area. The implementation plan for the care delivery
model was structured around the change management
model of Inspiration and Infrastructure, Education, and
Evidence.37 Inspiration involves creating a shared vision
of the future of nursing among stakeholders. Infrastructure means designing the processes, tools, roles, and
responsibilities to support the change. Education is required to convey the rationale and specific details of
new procedures, processes, roles, and responsibilities.
Evidence is defining the metrics and targets to evaluate
how the change is leading to the original vision. The
Leadership Launch, a day-long work session, was designed to inspire the informal nurse leaders and management team to champion the change on the units.
The leadership team included the shared governance
unit council members, charge nurses, unit clinical nurse
specialist, and managers. The team became immersed
in the guiding principles and practices of RBNP. The
infrastructure of the care delivery model was defined
as the processes, roles and responsibilities, and tools
needed to implement the practices, as well as a communication plan. The unit leadership team customized
the practices to the unique complexities and patientcare context.
Education about the change began with the leadership team’s communication plan and formal training
for each nurse prior to the start date. The 4-hour training session curriculum design included instructor-led
content on the vision, guiding principles, and 7 practices; staff nurse videos to show suboptimal and optimal handoff and focus-time processes; hands-on computer training for the handoff; and focused discussion
on likes, concerns, and possible issues and barriers to
success. Summary evaluation of the training enabled
improvements with each session. During the preparation preceding the start date, the unit leadership met
to track communication and resolution of issues and
barriers identified by the nurses during the training
sessions. Modeling robust relationships with coworkers and colleagues by the leadership team began with
the leadership launch and continued through the preparation, training, and implementation of RBNP. The evidence illustrating that the practices were leading to
improvements in patient satisfaction, nursing satisfaction, and patient safety were defined as metrics and
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RELATIONSHIP-BASED NURSING PRACTICE
IN MATERNITY
The maternity unit is a 52-bed, combined postpartum
and antepartum unit. There are 12 dedicated antepartum beds for high-risk patients with diagnoses ranging
from diabetes, pregnancy-induced hypertension, premature labor, and various types of adherent placentas. In 2010, there were 4582 births, of which 16 were
triplets and 226 were twins. The average cesarean delivery rate was 32% and the average length of stay was
3.2 days. In 2010, the ethnic makeup of the patient population was 41% Hispanic, 32.1% white, 21% Asian, 3%
African American, and 2.9% Pacific Islander. It is not uncommon to see patients with comorbidities such as human immunodeficiency virus, various cancers, asthma,
thrombophilia, and sickle cell disease. The maternity
unit receives transports from other counties determined
by neonatal or maternal morbidities. Couplet care is
practiced at the bedside, with a nurse-to-patient ratio
of 1:3 couplets for the first 4 hours of a 12-hour shift
(days or nights). The smaller ratio allows for better discharge preparation and more time at the bedside at
the beginning of each shift. The nurse-to-patient ratio is increased at 11 AM and 11 PM to 1:4 couplets.
With higher-acuity patients, such as those recovering
from postpartum hemorrhage, a 1:1 or 1:2 ratio is used.
Clinical outcomes from the implementation of RBNP
included those related to patient satisfaction, nursing
perception, and patient safety.
OUTCOMES IN MATERNITY
After implementation of the model, performance outcomes were measured to monitor the level of compliance of nurses performing the practices. This step is critical in determining whether the changes to care delivery can produce improved patient care outcomes. The
targets for team briefing were for it to occur on time,
at every shift, for no more than 5 minutes and be attended by all oncoming staff. The team-briefing checklist included start/stop times and attendance tracking
and was used to monitor the targets. The target for the
RN handoff process was that all nurses would be able
to demonstrate the process with a score of at least 90%
of the steps, using a standardized audit tool. Registered
nurse handoffs were observed and monitored by the
nurse manager, assistant nurse managers, and the clinThe Journal of Perinatal & Neonatal Nursing
ical nurse specialist. The target for focus time was that
all patients would receive focus time at each shift. Focus
time performance was tracked by the charge nurses and
was based on self-report by the bedside nurses. The target for debriefing was also 2-fold: It should occur within
the final 2 hours of every shift and include all nurses
on shift. The person conducting the debriefing documented issues and compliments using the debriefing
checklist. Compliance with the 4 practices met targets
of 80% to 90% during the first 2 weeks. Daily monitoring was adjusted to 3 to 4 times per week on varying
shifts. Any reduction in compliance targets resulted in a
period of increased monitoring, one-on-one coaching,
and reinforcement through email communications and
staff meetings.
SATISFACTION AND PATIENT SAFETY
OUTCOMES
The project team surmised that RBNP would improve
patient satisfaction with nursing care through enhanced
nurse-patient relationships. The organization mailed the
Press Ganey Family Satisfaction Survey38 to patients’
homes 10 days after discharge to evaluate patient satisfaction. Survey results were used to evaluate the impact
of RBNP on indicators related to nurse-patient relationships. The indicators selected were as follows: addressed emotional needs, kept the patient informed,
and treated the patient with respect. At about 7 months
postimplementation, the patient satisfaction scores of
the 3 indicators during that time period (October 2010
to May 2011) were compared with scores from the same
time period a year before (October 2009 to May 2010).
The mean score is the average of all responses to a specific question based on a Likert scale, in which a score
100
95
mean score
targets, which were built into the process for daily monitoring of the practices.
Implementation began in 2009, and by 2010, RBNP
was successfully implemented in the pediatric medical/surgical units. In the fall of 2010, RBNP was implemented in the maternity unit.
90
89.2
87.8
85
82.8
82.7
81.8
81.3
80
75
Addressed emotional needs
Kept you informed
10/1/09 – 5/31/10 n=632
Treated with respect
10/1/10 – 5/31/11 n=617
Figure 4. Obstetrics unit at Lucile Packard Children’s Hospital at Stanford Inpatient Survey: Press Ganey Associates,
Inc. Used with permission from Lucile Packard Children’s
Hospital.
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33
of 0 indicates Very Poor and a score of 100 indicates
Very Good (see Figure 4).
Although the improvements are small, a trend is in
the positive direction. Patient satisfaction scores significantly improved among Spanish-speaking patients during a 3-month trial of dedicated interpreter support for
focus time (see Figure 5).
The comments sections of the Press Ganey Surveys
have indicated positive response to RBNP. For example,
patients have mentioned the bedside handoff as one of
the highlights of their maternity experience, contrary to
nurses’ belief that going into patient rooms during the
early hours of the morning or late hours at night may
interrupt patients’ sleep.
To learn nurses’ perspectives on how the practices
influenced nursing care, the RBNP Nursing Impact Survey was developed and then administered 6 months
after implementation with a 59% response rate. Approximately 73% of respondents replied that team briefings
provided valuable information that helped nurses understand the unit and who they could assist. Teamwork
improved because of team briefing according to 69% of
the respondents.
The new handoff process was challenging for maternity nurses to adopt. The process required 3 “Plan, Do,
Study, Act” cycles39 to improve the flow of information
from the EMR. The standardized handoff process was
initially designed for use in pediatric acute care units.
The process had to be customized and streamlined so
that using it for an assignment of 4 mothers and 4 infants was achievable within the 25-minute change-ofshift timeframe. Prior to the start of RBNP in maternity,
a baseline survey found that only 29% of nurses in maternity reviewed the EMR during the handoff. Through
the RBNP Nursing Impact Survey, 96% of nurses responded that they used the standardized RN handoff
process, including review of the EMR. Not only was
there a new process to learn but many nurses also had
to learn how to access information in the EMR in a
concise and efficient manner. Because of the new RN
handoff process, 79% of nurses reported feeling better
prepared to assume responsibility for the patient’s care.
Although no preimplementation patient-safety data related to RN handoffs were available, perceived improvements in patient safety because of the handoff process
were striking: 68% of nurses reported that omissions, errors, duplications, or near misses were identified during
the handoff process. Nurses described 30 patient safety–
related issues, nearly 50% of which were medicationrelated, including documentation errors and verification
issues. Catching missed laboratory orders in the EMR resulted in early interventions and aborted care failures
(see Figure 6).
Focus time seemed simple to nurses at the outset, but
in practice proved to be challenging. Focus time challenges many nurses because it requires them to move
away from their standard checklist and reflect on what
the patient is saying and not saying. The use of Spanish
interpreters enabled nurses and Spanish-speaking patients to talk about personal issues, uncovering a case
of potential domestic abuse in 1 situation. According to
the Nursing Impact Survey, 81% of nurses agreed that
focus time helped them learn things to better address
patient needs and influence care. Debriefing was most
effective when nurses were asked for input individually by the charge nurses or management team within
the final 2 hours of each shift. Approximately 72% of
nurses reported that they gave important information
about what gets in the way of patient care. Through
the debriefing process, nonurgent issues were batched
all at once during the shift. The management team experienced fewer interruptions and was able to address
reported issues in a timelier manner.
100
95
mean score
92.9
92.4
90.3
90.0
90
87.8
86.4
85
85.6
84.9
80
75
Attended to special/personal
needs
Treated with respect Responded to concerns/complaints Addressed emotional needs
2/10 – 4/10
2/11 – 4/11
Figure 5. Obstetrics unit at Lucile Packard Children’s Hospital at Stanford Monolingual Spanish-Speaking Patients
Inpatient Survey: Press Ganey Associates, Inc. Used with
permission from Lucile Packard Children’s Hospital.
34
www.jpnnjournal.com
CHALLENGES AND FUTURE WORK
Changing long-held practices and behaviors in a healthcare environment can be daunting. The wave approach
to implementation enabled improvements in the implementation process with each new unit. The initial scope
of the project included all 7 practices. This proved to be
too much to monitor and manage for both the nurses
and the management teams. The implementation process was scaled down to include the first 4 practices
instead of all 7. Metrics and targets were standardized for the project so that outcomes data could be
compared across the organization. Some experienced
nurses seemed to have greater difficulty embracing the
standardized RN handoff and focus time. A common
expression was, “We already do this!” Reinforcing the
January/March 2012
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Other
information
issues, 10%
13% Medication omissions: medications not
given
23% Medication documentation errors:
Medication not charted; not charted on
time
13% Medication verification: errors or
questions about dose or rate
13% Laboratory: missed laboratory draws
10% Orders: duplicate or missed orders
17% Verification of care: clarifying tasks
not done from previous shift.
10% Other information issues: errors in
documentation
Medication omission, 13%
Verification of
care, 17%
Medication documentation
error, 23%
Orders, 10%
Laboratory,
13%
Medication verification,
13%
Figure 6. Patient-safety issues reported with RN handoff (N = 30). Used with permission from Lucile Packard Children’s Hospital.
concept of standardization to improve patient safety
and enhance nurse-patient relationships was key. Unit
management encouraged nurses to give recommendations during debriefing. Relaying positive patient and
family comments about focus time and introductions at
handoffs was also effective in reinforcing the value of
the changes.
A significant challenge of implementing RBNP in the
maternity units was monitoring the performance metrics and meeting the target goals. Multiple competing
priorities reduced capacity for monitoring, coaching, and performance counseling. A project steering
committee was formed to provide oversight and governance at the executive level. The management team
met periodically with the project steering committee
to give a status report of the targets and discuss issues
and barriers to successful sustainability. This process
promoted accountability and provided executive-level
support for the change process at the unit level. As
of September 2011, the organization is transitioning to
a model of continuous performance improvement.40
By shifting the focus of RBNP from a project with a
start and end date to being part of a daily management
system, monitoring of nurse performance will be made
a part of daily operations.
Nurses and nursing management continue the organization’s transitioning work with evaluation of the
care delivery model practices through Plan, Do, Study,
Act cycles. Phase II implementation will include standardizing the RN role in rounds, building a technologysupported integrated plan of care to optimize care
coordination functions, and improving the organization’s capacity for continuity of care through optimizing
The Journal of Perinatal & Neonatal Nursing
scheduling models. Finally, the future work in phase
II implementation will focus on relationship with self,
addressing self-advocacy, personal/professional development, and a holistic approach to work-life balance.
SUMMARY
To successfully implement a transition from a culture
of tasks, silos, and production pressures to a culture
with the nurse-patient relationship as the cornerstone,
nurses need leadership support and attention on an ongoing basis. The implementation of RBNP has driven a
change in how nurses in the maternity unit work together, communicate with patients and families, and
call out patient-safety concerns. These changes are the
beginning of the vision for healthcare described by the
Lucian Leape Institute.2 Focusing on the relationship
between the nurse and the patient places the patient’s
needs first. Building teamwork and improved communication between nurses and leadership is fostering transparency and respect. Joy and meaning in work come
from being able to spend time listening and learning
about what matters most to patients, and then being
able to act on what is learned. While cultural transformation takes years, a care delivery model provides the
common purpose, language, and infrastructure to drive
the transition forward.
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